Medicine For People!

October 2017

Medical Student Checking Blook Pressure
CC BY-SA 3.0, Link

State of the Art 2017

Navigating Medical Research

Doctors know what they know and do what they do because of their study and training, tempered by experience. A cardiac surgeon told me recently that his experience in high school shop class had enhanced his ability to perfect the mechanical aspects of his surgeries. Every doctor knows that the most important part of the surgeon is his brain, but without practiced hand-eye coordination and a builder's sense, the brain is not enough.

For all that, physicians remain alert to what the academics tell us in the profusion of medical journals, "which many imagine ... to be as dull as telephone directories and twice as obscure."[i] That obscurity can hide a host of inaccuracies.[ii]

For one thing, most medical journals are heavily subsidized by the same pharmaceutical companies that sponsor the research. A single study showing a benefit for fricasseed frogs' knuckles will be chopped in pieces and published in several different journals to magnify its marketing effect. Another study showing no benefit for the same remedy will sink without a trace. The statistical methods used can be faulty, even misleading. In response, the American Board of Internal Medicine and its Canadian counterpart are undertaking a Choosing Wisely campaign to analyze this flood of medical data and winnow the useful material from the dross. Their findings to date often modify earlier generally accepted guidelines.

The Best of 2017: Sometimes Less is More

Pneumonia

"A shorter course of antibiotics based on clinical stability is safe and effective for community-acquired pneumonia".[iii] The careful phrasing here tells us that this does not apply to people who developed pneumonia while in the hospital, nor to people who are clinically stable, meaning that they are beginning to recover from the pneumonia after 5 days.

Such details can be critical.

Blood Pressure

When treating high blood pressure in people over the age of 60, 150/90 or lower is the best target. When we push the blood pressure lower than this, we may harm the patient through an increased risk of falls and injuries.[iv]

Blood Sugar

Not too long ago, we thought it was best for people with diabetes if we kept their blood sugar strictly at normal levels. But now we see that we actually harm people in this way and their death rate is higher, probably related to trauma from hypoglycemia (when the blood sugar goes too low, which can happen as a result of overzealous treatment). As people age, they do better with even looser control.[v]

Cholesterol

While some physicians are holding out still on this one, the bulk of the evidence shows that people over the age of 70 do better with a higher cholesterol level, and those over 85 are better off not taking statins at all.[vi]

Quiz: How are These Changes Similar?

Here are the changes in the guidelines for treating conditions of most concern to the average patient. I'm leaving off the references. The conditions are listed alphabetically. See if you can figure out what the common theme is.

Cancer Screening

Colon Cancer

If you have a parent or sibling with colon cancer, but have not developed it yourself by age 55, your risk is no greater than that of the general population.

Colon Cancer Screening

People who have had a high-quality colonoscopy that found no evidence of precancerous lesions are at low risk of colon cancer for the next 10 years. They do not need screening during those 10 years by any means (either repeat colonoscopy or a test for hidden blood in stool). Your doctor can often read between the lines of the procedure report to judge the quality of the colonoscopy.

Women's Health

Abnormal Pap Smear

Not all abnormal Pap smears require treatment. When the biopsy shows cervical intraepithelial neoplasia 1, most of the time this represents a viral infection that will clear in less than a year.

Bladder Prolapse

Before resorting to surgery, consider use of a pessary (a device inserted in the vagina that helps hold the bladder in place).

Children

Childhood Seizures Associated with Fever

These are best managed without CT scans. The risk to the brain from radiation and from procedures to follow up on unusual but benign scans outweighs any possible benefit.

Teeth

The evidence for the benefits of fluoride toothpaste continues to mount. Use it.

Noggin Problems

Head Injury

Minor head injuries in children and adults are best managed with observation alone. Brain tissue is especially sensitive to radiation and unnecessary CT scans pose considerable danger.

Headache

Except in the unusual case that a person shows signs of a tumor or other structural abnormality of the brain, imaging is more likely to lead to harm, including unnecessary expense, than it will be of benefit.

Cholesterol: Round Two

Fractionated Cholesterol Profile

There are a number of laboratories and other commercial interests pushing these fancy cholesterol profiles. We did these years ago until we discovered what is now well-known today: lipid profiles that include various types of LDL and HDL cholesterol are valuable only for intermediate- to high-risk patients only.

Cholesterol Treatment

"Statin therapy should be used to reduce arteriosclerotic cardiovascular disease risk in individuals likely to have a clear net benefit (those with clinical arteriosclerotic cardiovascular disease) or in primary prevention for adults with low-density lipoprotein cholesterol levels over 190 mg/dL, those aged 40 to 75 years with diabetes, and those with a 10-year arteriosclerotic cardiovascular disease risk of 7.5% without diabetes. A clinician–patient discussion that considers potential arteriosclerotic cardiovascular disease risk reduction, adverse effects, and patient preferences is needed to decide whether to initiate statin therapy, especially in lower-risk primary prevention."

These discussions usually include plugging an individual patient's blood pressure reading, smoking habits, laboratory measurements, and family history into an online calculator to determine what benefit that person might get from going on a statin. Each case may be different.

End of Life Care

Life-Threatening Illness

Too often we delay palliative care, also known as hospice care, until all treatment measures have failed. People seem to live longer when hospice care is started sooner, even while they are undergoing treatment for their illness, and their quality of life is better. The Europeans have been doing this longer than we have with good results.

Dementia

When a person with advanced dementia is not eating enough, doctors are advised not to insert a feeding tube. People who have a feeding tube in place often become agitated, require restraints, and incur an increased risk of pressure ulcers, all of which outweigh any benefit of the feeding tube.

Conclusion

The answer to the quiz is that in almost all of these cases, less is indeed more. Less medication and fewer tests prolong life and reduce suffering. The exception is earlier resort to palliative care when people are suffering. While we often over-prescribe narcotic pain relievers, we also sometimes fail to use them when people need them.

Each of these examples applies to specific situations. It is not the doctor's job to just hand you an antibiotic or a pain pill or a test. The doctor's job is to determine what is going on and choose the Goldilocks response: not too much, not too little, but just right.

Endnotes

[i] Richard Smith Journal of the Royal Society of Medicine, 2006;99:115

[ii] http://www.cdnsciencepub.com/blog/21st-century-science-overload.aspx

[iii] Journal of the American Medical Association Internal Medicine 2016, volume 176, page 1257.

[iv] http://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=267

[v] http://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=16

[vi] http://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=98

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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.